Book Review by Michal Klau-Stevens
NYU University Press
©2013 by New York University
What is driving the high rate of cesarean section births in America? This is the question that Theresa Morris seeks to answer in her book, Cut It Out. The rate of births by cesarean section is so high now that the damage to women and babies is greater now than the risks it is meant to alleviate. Morris calls it “a paradox” that obstetricians and hospitals, sworn to promote the health of individuals, know this yet continue to perform numerous surgeries.
While the current way of thinking places the lion’s share of blame for the cesarean crisis at the feet of pregnant women and the care providers, Morris suggests that, “the increasing c-section rate is a result of the way that health care organizations have responded to their legal and economic environments.” Her work uncovered major stressors at the organizational level which constrain the choices of both expectant women and health care providers and which lead them to enact certain behaviors even though those behaviors do not lead to improved outcomes.
Morris is a sociology professor at Trinity College in Hartford, Connecticut. She applies the theories of Max Weber, a founder of sociology, who tells us that, “to understand societal behaviors and trends one must look at the meaningful action of people involved in decisions that lead to those behaviors and trends.” Furthermore, to understand the organizational and societal roots of the problem, one must understand the experiences of the players involved in order to understand the reasons for their actions. In order to gain this empathetic viewpoint, Morris interviewed fifty maternity care providers, including obstetricians, family practice doctors, midwives, and labor and delivery nurses. Her team also interviewed eighty-three postpartum women at a Connecticut hospital.
In interview after interview with doctors, midwives, and nurses Morris found that the threat of liability was the most influential factor in how care is ultimately provided for birthing women. Although the number of lawsuits against providers has not increased over time, the amount of money paid out has increased drastically. This has led to crushing malpractice insurance costs that cause doctors to feel trapped in the profession of obstetrics; unable to practice in a manner they believe will lead to positive outcomes, fearing that the next birth they attend could be the one poor outcome that costs them their careers, their homes, and possibly their life-savings. They are also unable to leave the profession without paying huge fees to cover the costs of possible future lawsuits from births attended up to 12 years prior.
Because the malpractice liability awards have achieved astronomical levels, up to a $58.6 million award in Connecticut in 2011, organizations try to standardize practice and minimize risk in every aspect of caregiving. From the patient safety movement and its practice of standardization, to peer reviews, quality measures, the use of technology, and to the lack of adherence to high-quality evidence at the organizational level when creating care guidelines, Professor Morris finds that the liability threat consistently rears its ugly head. In discussions of every aspect of care that birth advocates find to be areas of concern, such as continuous fetal monitoring and lack of access to VBAC, Morris draws out the lens and provides a much wider viewpoint that encompasses both the characters on the stage; the expectant parents and their doctors and nurses, and also shows the puppet masters – the hospital administrators and risk managers, insurers, and organizations involved in creating the rules that caregivers and patients must follow. She then draws the lens out even further to encompass the theater where the whole show takes place; the malpractice system in our country and the regulations and health care laws that ultimately guide all decision making.
While we often focus on doctors and midwives as being the key decision makers in maternity care, the organizations that create the care environment, including not only hospitals and insurers but also the medical liability system and state and federal governments, are the true arbiters of acceptable care. If the priorities at the highest levels of the organizations involved were adequately addressed to remove the organizational disincentives to practicing appropriate, less interventive care, the cesarean rate would go down. Understanding the root cause of the high cesarean rate gives us the opportunity to redirect our efforts as advocates working to promote evidence-based care.
At the end of the book Professor Morris offers a number of solutions which could be undertaken by maternity care participants at each level of activity. She has suggestions for birthing women, care providers, hospitals, insurers, ACOG, and medical schools. She also recommends two long-term societal solutions – reforming the malpractice system in the United States and moving towards a less medicalized system for birth that promotes midwifery care and out-of-hospital birth.
Thoroughly referenced and somewhat academic in tone, Cut It Out is full of information that will be useful to birth advocates to gain a broader understanding of the organizational factors that influence the high rate of cesareans in the United States. There are numerous quotes from caregivers in the book which give a more nuanced understanding of the pressures, concerns, and thought processes that come into play from their perspective. Some birth advocates may find that the book is overly sympathetic to the concerns of doctors even while they continue to cause women and babies harm by over-using cesarean surgery. Professor Morris’ contention is that there are larger forces at work that are forcing doctors’ hands, and if we address those forces we will, over time, have more success in reducing the cesarean rate.
You can watch a video of Professor Theresa Morris discussing why she wrote “Cut It Out” by following the link below:
Also, receive 20% off when you purchase the book by entering MORRIS as the promo code! This offer is available until 1/1/2014.